Child’s Name: …………………………………………………………………………….Date of Birth: ......
Leader’s notes:
Home Address……………………………………………………………………………..………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………School ……….……………………………………………………………….
Family Doctor …………………………………………… Surgery address ……………………………………………………………………………………..
Religion/faith ………………………………………………..… Medical/ethical food restrictions ………………………………………………………………..
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Medical conditions (e.g. hearing difficulty, sight difficulty, allergies, asthma) and details of care required during Scouting activities:
....………………………………………………………………………………………………………………………………………………………………………..
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…………………………………………………………………………………………………………………………………Continued on back of form YES/NO
Parent/Guardian’s Name……………………………………………………….…. Relationship to child ...……………………………………………………
Parent’s occupation …………………………………………………………………………………………………………………………………………………
Phone Numbers ……………………………………………………………………………………………………….…………………………………………….
....………………………………………………………………………………………………………………………………………………………………………..
Email Address ……………………………………………………………………………………….……………………………………………………………….
Please circle whether you would be willing to help: most weeks / occasionally / with camps and outings / with events / on the committee
PARENTAL CONSENT (please delete as appropriate)
- I am willing for my son/daughter to join the Scout Group and I will encourage him/her to attend regularly and I will pay for his/her uniform, subs and participation fees.
- I understand that I may be required to remove my son/daughter from a Scouting activity at very short notice.
- I will endeavour to keep the Leaders informed of how to contact me / another appropriate responsible adult member of the family during all Scout activities.
- I accept that the 1st Deben Valley Scout Group will be keeping information about my son’s/daughter’s membership of the Scout Movement for Scouting purposes
- I give my explicit consent to the holding of information of my son’s/daughter’s: health; disabilities; religion or faith; race or ethnic origin for Scouting purposes.
- I understand that photographs and video images of Scouts taking part in activities may be submitted in the local newspapers, the Group, District or County newsletters and websites; or put on display according to the Scout Association guidelines. I give consent to my son/daughter’s image beingused in this way.
- I understand that Leaders do their best to “act as a responsible parent would do in the circumstances” with regard to first aid and medical matters and I will endeavour to keep the Leaders informed of my son’s/daughter’s health status and needs.
- I would like 1stDeben Valley Scout Group to treat all payments I make as Gift Aid Donations from the date of this declaration until I notify you otherwise.*
Signed ………………………………………………………………Date ……………………………….
None of the information provided will be passed to any third parties outside the Scout Movement without your consent.
* You must pay an amount of Income Tax and/or Capital Gains Tax at least equal to the tax that the charity reclaims on your donations in the appropriate tax year. Version Date: 24/06/2013